a medication safety huddle “#druggle · a medication safety huddle watford general hospital ....

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“#DRUGgle” @drashleyreece Zahida Hassandin Premji Lead Pharmacist for Paediatrics Dr Ashley Reece Consultant Paediatrician A Medication Safety Huddle Watford General Hospital

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Page 1: A Medication Safety Huddle “#DRUGgle · A Medication Safety Huddle Watford General Hospital . Driver Diagram The Goals Towards zero drug errors Primary Drivers Reduced prescription

“#DRUGgle”

@drashleyreece

Zahida Hassandin Premji

Lead Pharmacist for Paediatrics

Dr Ashley Reece

Consultant Paediatrician

A Medication Safety Huddle

Watford General Hospital

Page 2: A Medication Safety Huddle “#DRUGgle · A Medication Safety Huddle Watford General Hospital . Driver Diagram The Goals Towards zero drug errors Primary Drivers Reduced prescription
Page 3: A Medication Safety Huddle “#DRUGgle · A Medication Safety Huddle Watford General Hospital . Driver Diagram The Goals Towards zero drug errors Primary Drivers Reduced prescription

Driver Diagram

The Goals

Towards zero drug

errors

Primary Drivers

Reduced prescription

errors

Reduced administration

errors

Secondary Drivers

Doctor/Nurse ownership

Projects

DRUG-gle

Induction teaching/test

Ward Round chart review

On-ward chart review

Culture of drug safety

Pharmacists/team integration

Page 4: A Medication Safety Huddle “#DRUGgle · A Medication Safety Huddle Watford General Hospital . Driver Diagram The Goals Towards zero drug errors Primary Drivers Reduced prescription
Page 5: A Medication Safety Huddle “#DRUGgle · A Medication Safety Huddle Watford General Hospital . Driver Diagram The Goals Towards zero drug errors Primary Drivers Reduced prescription
Page 6: A Medication Safety Huddle “#DRUGgle · A Medication Safety Huddle Watford General Hospital . Driver Diagram The Goals Towards zero drug errors Primary Drivers Reduced prescription
Page 7: A Medication Safety Huddle “#DRUGgle · A Medication Safety Huddle Watford General Hospital . Driver Diagram The Goals Towards zero drug errors Primary Drivers Reduced prescription

DRUG-gle

• At end of Grand Round/Handover

• Pharmacist led

• Key interventions from past week

• Summary circulated

Page 8: A Medication Safety Huddle “#DRUGgle · A Medication Safety Huddle Watford General Hospital . Driver Diagram The Goals Towards zero drug errors Primary Drivers Reduced prescription
Page 9: A Medication Safety Huddle “#DRUGgle · A Medication Safety Huddle Watford General Hospital . Driver Diagram The Goals Towards zero drug errors Primary Drivers Reduced prescription
Page 10: A Medication Safety Huddle “#DRUGgle · A Medication Safety Huddle Watford General Hospital . Driver Diagram The Goals Towards zero drug errors Primary Drivers Reduced prescription

• “Let’s do the #DRUGgle”

• #NEOdruggle

• #NURSINGdruggle

Local Spread…

Page 11: A Medication Safety Huddle “#DRUGgle · A Medication Safety Huddle Watford General Hospital . Driver Diagram The Goals Towards zero drug errors Primary Drivers Reduced prescription

#DRUGgle

National Spread…

Page 12: A Medication Safety Huddle “#DRUGgle · A Medication Safety Huddle Watford General Hospital . Driver Diagram The Goals Towards zero drug errors Primary Drivers Reduced prescription

#DRUGgle

Examples of key messages

Transcription error

Regular medications

Levels

Interactions/effects

Metolazone prescribed instead of mesalazine.

Lanzoprazole: Taking 15mg at home; prescribed at 50mg

Gentamicin: Reminder levels on day 2 and 5. Day 5 level had been missed

Ciprofloxacin and epilepsy:

It can reduce seizure threshold

Type of error Details Details

Page 13: A Medication Safety Huddle “#DRUGgle · A Medication Safety Huddle Watford General Hospital . Driver Diagram The Goals Towards zero drug errors Primary Drivers Reduced prescription

Acknowledgements

“#DRUGgle”

@drashleyreece

SAFE team:

Peter Lachman, Darren Cooper

Leeds Teaching Hospitals

Neonatal Unit

Paediatric Pharmacists:

Zahida Hassandi

Anupam Paul

Maddie Wong

Alistair Hill